A case of a long-term survival achieved by surgical treatment and chemotherapy for late recurrence of AFP-producing gastric cancer.

BACKGROUND: Alpha-fetoprotein-producing gastric cancer (AFP-GC) is a relatively rare disease, with a dismal prognosis. CASE PRESENTATION: We report the case of a patient with long-term survival after surgery for the recurrence of AFP-GC. A 71-year-old man was diagnosed with gastric cancer and underwent distal gastrectomy with D2 lymphadenectomy (pT3N2M0). Pathological examination of the resected specimen revealed AFP-GC. Fifteen years after the gastrectomy, the patient experienced anorexia and was admitted with a mass located at the mesentery of the small intestine. Following a diagnosis of gastrointestinal stromal tumor of the mesentery, a tumor resection with partial small intestine was performed. The final histopathological diagnosis was AFP-GC's recurrence in the small-bowel mesentery. Two months later, multiple liver metastases were identified, and serum AFP level was found to be extremely high (17,447 ng/mL). Chemotherapy with S-1+CDDP (SP) was initiated for liver metastasis. However, owing to anorexia and fatigue, SP therapy was discontinued following the patient's request at the end of two courses. A CT scan at 1 month after the discontinuation of chemotherapy did not reveal liver metastasis, and serum AFP level decreased to the normal range. He is alive at present with no re-recurrence and no elevation of serum AFP level at 7 years after the second surgery without any chemotherapy. CONCLUSION: Even if recurrence of AFP-GC is diagnosed, radical resection and chemotherapy are effective, as noted in the present case.

Long-term outcome following sentinel node navigation surgery for cT1 gastric cancer.

Sentinel node navigation surgery (SNNS) has become a standard procedure for early-stage melanoma and breast cancer. However, very few studies have evaluated the long-term clinical outcomes following SNNS for gastric cancer. The present study analyzed 51 patients with cT1 gastric cancer who underwent SNNS at our hospital. Sentinel nodes (SNs) were identified using the dual tracer method. Patients underwent limited gastrectomy with SN station dissection when the SNs were reported as pathologically negative during surgery. When SNs were pathologically positive, standard gastrectomy with D2 lymphadenectomy was performed. Out of the 51 cases, 42 cases (82%) were pathologically diagnosed as SN-negative using a frozen section. The surgical procedures included segmental gastrectomy (n=33) and local resection (n=9). A total of 9 patients (18%) had lymph node metastasis in SNs. The mean observation period was 3,125±167 days, and the 5-year overall survival rate was 98%. There was no recurrence, and body weight loss was minimal following the SNNS. Remnant gastric cancer developed in 4 (8%) of the 50 patients except total gastrectomy. Thus, SNNS was a useful procedure for cT1 gastric cancer from the long-term clinical outcomes, though metachronous gastric cancer should paid further attention to.

MET4 expression predicts poor prognosis of gastric cancers with Helicobacter pylori infection.

The role of HGF/SF-MET signaling is important in cancer progression, but its relation with Helicobacter pylori-positive gastric cancers remains to be elucidated. In total, 201 patients with primary gastric carcinoma who underwent curative or debulking resection without preoperative chemotherapy were studied. MET4 and anti-HGF/SF mAbs were used for immunohistochemical analysis. Survival of gastric cancer patients was estimated by Kaplan-Meier method and compared with log-rank. Cox proportional hazards models were fit to determine the independent association of MET-staining status with outcome. The effect of live H. pylori bacteria on cell signaling and biological behaviors was evaluated using gastric cancer cell lines. MET4-positive gastric cancers showed poorer prognosis than MET4-negative cases (overall survival, P = 0.02; relapse-free survival, P = 0.06). Positive staining for MET4 was also a statistically significant factor to predict poor prognosis in H. pylori-positive cases (overall survival, P < 0.01; relapse-free survival, P = 0.01) but not in H. pylori-negative cases. Gastric cancers positively stained with both HGF/SF and MET4 showed a tendency of the worst prognosis. Stimulation of MET-positive gastric cancer cells with live H. pylori bacteria directly upregulated MET phosphorylation and activated MET downstream signals such as p44/42MAPK and Akt, conferring cell proliferation and anti-apoptotic activity. In conclusion, positive staining for MET4 was useful for predicting poor prognosis of gastric cancers with H. pylori infection. Helicobacter pylori stimulated MET-positive gastric cancers and activated downstream signaling, thereby promoting cancer proliferation and anti-apoptotic activity. These results support the importance of H. pylori elimination from gastric epithelial surface in clinical therapy.

Preferentially examined sentinel nodes for sentinel node navigation surgery in gastric cancer.

The intraoperative examination of the sentinel nodes (SNs) is crucial for correctly performing SN navigation surgery (SNNS). Frozen-section diagnosis is ordinarily used; however, when several SNs are being assessed in gastric cancer, which has numerous regional lymph nodes, it is difficult to examine them all correctly within the short duration of surgery. In the present study, we aimed to determine the SNs that should be preferentially examined during SNNS in gastric cancer. A total of 824 SNs were examined in 113 patients with clinically determined T1-2 gastric cancer and no apparent lymph node metastasis. We focused on the accumulation of tracers expressed by hot nodes (HNs) using the radioisotope (RI) method and green nodes (GNs) using the dye-guided method and measured the radioactivity count of the HNs (RI count). We compared these parameters between 35 metastatic and 789 non-metastatic SNs. The percentage of metastasis-positive SNs that were radioactively 'hot' and dyed green was higher compared with that of the negative SNs (89 vs. 43%, respectively; P<0.01). The RI counts of the metastasis-positive SNs were higher compared with those of the negative SNs [median (range): 361 (0-10,670) vs. 53 (0-9,931), respectively; P<0.01]. The area under the receiver operating characteristic curve of the RI count was 0.69 (95% CI: 0.60-0.78). Therefore, when assessing several SNs, those with higher RI counts (HNs and GNs) should be preferentially examined. Further accumulation of cases is required to establish the cut-off value for the diagnosis of metastasis based on the RI count.

Multidetector-computed tomography attenuation values between the tumor and aortic wall in response to induction therapy for esophageal cancer and its predictive value for aortic invasion.

The objective of this study was to evaluate the multidetector computed tomography (MDCT) attenuation value between the tumor and aorta in response to the induction therapy for esophageal cancer. In advanced esophageal cancer, the main reason for unresectability is the local invasion of the tumor into the aorta or trachea. Despite remarkable advances in diagnostic modalities, pre-operative assessment of pathological response and local tumor extent in esophageal cancer remains difficult. MDCT attenuation values between the tumor and aorta, and the contact angle of the tumor to the aorta (Picus' angle) were retrospectively evaluated in patients with esophageal cancer who underwent induction therapy in terms of predicting the pathological response, aortic invasion and prognosis of esophageal cancer. The induction therapy may increase the tumor-to-aorta distance and decrease the maximum tumor size and Picus' angle. When the tumor-to-aorta cut-off value was set at <1.3 mm, the accuracy of this distance for aortic invasion was 94.6%. In terms of this distance, 14 out of 19 patients with a tumor-to-aorta distance of <1.3 mm prior to the induction therapy had a distance of >1.3 mm following therapy and underwent curative resection. The assessment of the MDCT attenuation value between the esophageal tumor and the aorta is simple and objectively assesses the response to the induction therapy and aortic invasion in esophageal cancer. This method should be applied to predict the response to the induction therapy and to prevent unnecessary surgery in patients with tumors involving the aorta.

Systemic inflammatory response syndrome as a predictor of anastomotic leakage after esophagectomy.

PURPOSE: Esophageal anastomotic leakage is still a major cause of morbidity and mortality after esophagectomy. We conducted this study to elucidate how anastomotic leakage affects the systemic inflammatory response syndrome (SIRS) criteria. METHODS: The subjects of this retrospective study were 61 patients who underwent esophagectomy. We evaluated their preoperative status, the surgical procedures, and postoperative systemic response, including white blood cell count, heart rate, respiratory rate, body temperature, and laboratory data up to postoperative day (POD) 4. RESULTS: Anastomotic leakage developed in nine patients (14.8%) and was found on POD 7 on average. These patients had a significantly longer hospital stay than those without leakage. Although no difference was observed in postoperative changes of any of the SIRS criteria, the postoperative incidence of SIRS was significantly higher in the patients with anastomotic leakage on POD 4. The number of positive criteria for SIRS was also significantly higher in patients with anastomotic leakage than in those without leakage on PODs 3 and 4. CONCLUSIONS: The SIRS scoring system is valuable for evaluating the severity of systemic inflammatory response caused by anastomosis leakage, and may serve as an indicator for prompt management.

Sentinel node navigation surgery attenuates the functional disorders in early gastric cancer.

The purpose of this study was to evaluate the merits of the sentinel node (SN)-navigated reduced gastrectomy (SNRG) procedure. The subjects (sT1N0) were divided into the SNRG group (n=34) and the GL group, that consisted of patients which underwent gastrectomy according to the Japanese Gastric Cancer Association guidelines (n=33). We compared the area of the resected stomach and evaluated their body weight changes, and the results of a questionnaire survey about postoperative symptoms, and nutritional effects by blood tests administered at postoperative months (POM) 3, 6 and 12. The median area of the resected stomach was 104 cm2 in the SNRG group vs. 192 cm2 in the GL group. The body weight loss ratio was -5.9±5.8 vs. -9.3±4.1% at POM 3, and the henoglobin (g/dl) change rate was -1.1±7.9 vs. -6.4±6.5% at POM 12 in the SNRG and GL groups, respectively. There were no significant differences regarding the passage of food, reflux, the incidence of dumping syndrome, digestive and excretory function, or general condition and the satisfaction levels of the patients. In conclusion, SNRG has some advantages over GL in terms of postoperative disorders for at least one year after surgery, and is the recommended choice of a surgical procedure for early gastric cancer.

Optimal size of jejunal pouch as a reservoir after total gastrectomy: a single-center prospective randomized study.

BACKGROUND: In order to improve a patient's quality of life after total gastrectomy, jejunal pouch reconstruction has been employed. However, little information exists regarding the optimal size of the jejunal pouch after total gastrectomy. METHODS: The study was designed as a single-center randomized trial in which the results of double-tract reconstruction with pouches of two different sizes were compared, i.e., short and long pouch double tract (SPDT and LPDT, respectively). We conducted a clinical assessment with standard questionnaire after surgery. The amount of residual food in the jejunal pouch was determined by endoscopy. RESULTS: No demographic differences were noted between the two groups. The eating capacity per meal was higher in the SPDT group than in the LPDT group. The postoperative weight loss 24 months after surgery was lower in SPDT group than that in the LPDT group. Although the incidence of early dumping symptoms was higher in the SPDT group, no difference was noted in the other postprandial abdominal symptoms between the two groups. CONCLUSIONS: We conclude that the optimal pouch should be relatively short, as a short pouch improves the eating capacity per meal and the weight loss ratio to the preoperative value.

One-step nucleic acid amplification (OSNA) for the application of sentinel node concept in gastric cancer.

PURPOSE: This study was designed to apply safely the sentinel node navigation surgery (SNNS) to the malignancies, an accurate and prompt intraoperative diagnosis of SN is essential, and micrometastasis has been frequently missed by conventional frozen sections. Recently, a novel molecular-based rapid diagnosis for the lymph node (LN) metastases has been developed using (OSNA) in breast cancer, which takes approximately 30 min to obtain a final result. We evaluated the efficacy of OSNA in terms of the intraoperative diagnosis of LN metastasis in patients with gastric cancer. METHODS: A total of 162 LNs dissected from 32 patients with gastric cancer was included in this study; 45 LNs were pathologically diagnosed as metastatic LNs and 117 LNs were negative. The LNs were bisected; halves were examined with H&E stain, and the opposite halves were subjected to OSNA analyses of CK19 mRNA. The CK19 mRNA expression was examined in the positive or negative metastatic LNs, and the correlation between the tumor volume and CK19 mRNA expression in the metastatic LNs was examined. RESULTS: The CK19 mRNA expressions in the positive metastatic LNs were significantly higher than those of negative LNs. When 250 copies/µl was set as a cutoff value, the concordance rate was 94.4%, the sensitivity was 88.9%, and the specificity was 96.6%. The OSNA expression was significantly correlated with the estimated tumor volumes in the metastatic LNs. CONCLUSIONS: The OSNA method is feasible and acceptable for detecting LN metastases in patients with gastric cancer. This should be applied for the intraoperative diagnosis in the SN-navigation surgery in gastric cancer.

Roles of inflammatory cytokines in the progression of gastric cancer: friends or foes?

Increasing evidence is being reported regarding the hypothesis that several proinflammatory and anti-inflammatory cytokines may promote tumor progression and affect the host antitumor response. However, the manner in which a local cytokine network operates in tumor development remains unclear. We reviewed the literature to examine the consequences of novel insights into inflammatory cytokines associated with gastric cancer progression. The Medline and EMBASE databases were searched for publications regarding the role of inflammatory cytokines in the development of gastric cancer. A number of studies have suggested that several proinflammatory and anti-inflammatory cytokines promote tumor progression through the direct activation of nuclear factor-κB (NF-κB) and the upregulation of angiogenesis and adhesion molecules. Furthermore, these processes suppress host antitumor immunity, leading to tumor progression and metastasis. In patients with advanced gastric cancer, most cytokines that enhance or suppress host antitumor immunity appear to have elevated serum and local expression levels. The net cytokine environment fluctuates at various stages of tumor development. In conclusion, a more detailed understanding of the differential roles of malignant cell-derived and hostderived cytokines at different stages of the malignant process could, consequently, open new avenues for the manipulation of cytokine expression and function in cancer immunotherapy for gastric cancer.

Gastric tube reconstruction by laparoscopy-assisted surgery attenuates postoperative systemic inflammatory response after esophagectomy for esophageal cancer.

BACKGROUND: Conventional open procedures have been supplanted in part by less invasive approaches, such as laparoscopic surgery developed for treating gastrointestinal malignancies. However, it is unclear whether laparoscopy-assisted gastric tube reconstruction (LAGT) can attenuate the postoperative systemic inflammatory response after esophagectomy for esophageal cancer. METHODS: We investigated the postoperative clinical course of the systemic inflammatory response syndrome (SIRS) in patients who underwent an esophagectomy for esophageal cancer by LAGT (LAGT group) and gastric tube reconstruction by conventional open surgery (Open group). RESULTS: Compared with the Open group, the LAGT group had a significantly shorter operative time (539.6 min vs. 639.8 min), shorter duration of postoperative mechanical ventilation (1.1 days vs. 2.8 days), and shorter length of stay in the intensive care unit (2.1 days vs. 4.4 days). The LAGT group also had a significantly shorter SIRS duration (1.4 days vs. 2.7 days), a significantly lower incidence of SIRS, and a smaller number of positive SIRS criteria. Throughout the investigation period, the postoperative white blood cell count was lower in the LAGT group than in the Open group. Additionally, in the LAGT group, the heart rate was lower on each postoperative day (POD), and the respiratory rate was significantly lower on postoperative days (PODs) 1 and 4. There was no difference in postoperative oxygenation, morbidity, and mortality between the groups. The C-reactive protein level on PODs 3 and 4 was significantly lower in the LAGT group than in the Open group. CONCLUSIONS: Laparoscopy-assisted gastric tube reconstruction significantly attenuates postoperative SIRS, and it is therefore a potentially less invasive surgical procedure.

Computed tomography lymphography for the detection of sentinel nodes in patients with gastric carcinoma.

The sentinel node (SN) concept has been found to be feasible in gastric cancer. However, the lymphatic network of gastric cancer may be more complex, and it may be difficult to visualize all the SN distributed in unexpected areas by conventional modalities. In this study, we evaluate the feasibility and efficacy of CT lymphography for the detection of SN in gastric cancer. A total 24 patients with early gastric cancer were enrolled in the study. Three modalities (CT lymphography, dye and radioisotope [RI] methods) were used for the detection of SN. The images of CT lymphography were obtained at 10 min after injection of contrast agents. The SN were successfully identified by CT lymphography in 83.3% of patients; detection rates by the dye and RI methods were 95% and 100%, respectively. Most patients, in whom SN were successfully detected by CT lymphography, had positive results at 5 min after injection of the contrast material. The SN stations detected by CT lymphography were consistent with or included those detected by dye and/or RI methods. In conclusion, CT lymphography for the detection of SN in gastric cancer is feasible and has several advantages. However, based on this initial experience, CT lymphography had a relatively low detection rate compared with conventional methods, and further efforts will be necessary to improve the detection rate and widen the clinical application of CT lymphography for the detection of SN in gastric cancer.

Prognostic significance of the number of lymph nodes examined in colon cancer surgery: clinical application beyond simple measurement.

OBJECTIVE: To identify an optimal cutoff value for the number of lymph node examined (NLNE) to distinguish the prognoses in patients following a curative resection for advanced colon cancer, to clarify the mechanism of the difference, and to suggest the integration of NLNE to colon cancer staging. PATIENTS AND METHODS: A total of 859 patients who had undergone surgical treatment for localized colon cancer from 1980 to 2000 were reviewed. This was a cohort from a single institution with mean NLNE of 20.7 and more than 12 NLNE in 77% of the patients. The optimal breakpoint for NLNE was calculated by a receiver operating characteristic curve (ROC) analysis. The patients were stratified into groups based on various parameters and underwent univariate and multivariate analyses with respect to survival. RESULTS: The ROC analysis identified NLNE as a significant prognostic factor with cutoff value of 18 for node-negative and 20 for node-positive patients. A multivariate analysis with these cutoff values identified NLNE as a significant prognostic factor independent of tumor depth and the number of lymph nodes involved. The 5-year cause-specific survival of stage IIB patients was 96.5% with 18 or more NLNE and 67.5% with NLNE less than 18 (P[r]=0.0067). Similarly, a cutoff value of 20 NLNE for node-positive patients separated the 5-year cause-specific survival of stage IIIB patients into 79.3% with 20 or more NLNE and 63.3% with less than 20 NLNE (P=0.0052). CONCLUSIONS: The clinical significance of NLNE is not limited to being a benchmark for quality care, but has a definite benefit as a prognostic indicator across the stages. Patients could be stratified more efficiently by the integration of NLNE to TNM staging.

Has the accuracy of preoperative diagnosis improved in cases of early-stage gastric cancer?

BACKGROUND: Adequate preoperative evaluation for gastric cancer staging is essential to develop an individualized treatment strategy involving surgery with reduced lymphadenectomy and laparoscopic gastrectomy. METHODS: A total of 509 gastric cancer patients with clinical Stage IA or IB disease were divided into two groups: 304 patients were admitted in 2000 or earlier (Group A), and 205 patients were admitted in 2001, when multidetector computed tomography (MD-CT) was available, or later (Group B). We evaluated the accuracy of the preoperative diagnoses of tumor depth, lymph node involvement, and tumor stage. RESULTS: With respect to tumor depth, 94.5 and 52.8% of patients were staged correctly in cT1 and cT2 patients, respectively. Among both cT1 and cT2 patients, the underestimated rates were lower in Group B than in Group A. For nodal metastasis, 83.2 and 30.0% of patients were staged correctly in cN0 and cN1 patients, respectively. Among the cN0 patients, 82.1 and 84.7% of Group A and Group B patients, respectively, were staged correctly. Among the cN1 patients, none of the patients in Group B was underestimated, while 9.7% of Group A patients were underestimated. There was a significant increase in the percentage of correctly staged patients and a decrease in the percentage of underestimated patients in Group B in comparison to Group A in both cStage IA and cStage IB patients. CONCLUSIONS: Remarkable advances have been observed in the accuracy of preoperative staging in the early stage of gastric cancer. However, it is necessary to continue to develop accurate preoperative and intraoperative diagnostic systems.

Isolated gastric metastasis from renal cell carcinoma 19 years after radical nephrectomy.

Metastatic tumors in the stomach are rare. We report a case of solitary gastric metastasis from renal cell carcinoma (RCC) 19 years after radical excision of the primary tumor. During evaluation for anemia with melena, a small elevated tumor with ulceration was detected in the gastric fundus of this patient. The tumor was diagnosed as RCC based on endoscopic biopsy findings. There was no evidence of any other metastatic lesion, and a wedge resection of the stomach was performed. No additional metastasis or recurrence has been detected in the patient 12 months after discharge. This case confirms the existence of a very slow growing type of RCC with the potential for late solitary metastases and describes the surgical resectability.

Outcomes for patients following hepatic resection of metastatic tumors from gastric cancer.

PURPOSE: Although several studies have reported the efficacy of hepatic resection for the long-term survival of patients with gastric cancer metastases, the optimal treatment remains to be determined. METHODS: Seventeen patients underwent a hepatic resection for gastric cancer metastases at the National Defense Medical College Hospital. We retrospectively analyzed the clinical outcomes of surgical resection and identified factors associated with prognosis for patients who underwent hepatectomy for gastric cancer metastases. RESULTS: In 17 patients, the accumulated 5-year survival rate after hepatic resection was 31.5% and the median survival time was 34 months. Univariate and multivariate analyses showed that gastric tumors less than 6.0 cm and D2 lymphadenectomy were the most important predictors of survival. The five patients who survived more than 5 years after hepatic resection had a D2 lymphadenectomy, modest lymphatic invasion, primary gastric tumors less than 6.0 cm, and a solitary liver metastasis. CONCLUSION: Although recent progress in adjuvant therapy should be the key to a good prognosis, we believe that surgical resection may bring some hope of long-term survival for judiciously selected patients with hepatic metastases from gastric cancer.

Postoperative infections are associated with adverse outcome after resection with curative intent for colorectal cancer.

This study focused on the impact of post-operative infection on patient outcome after resection with curative intent for colorectal cancer. Postoperative surgical and medical complications have been implicated as a negative predictor of long-term outcome in various malignancies. We studied a population of 1083 patients who underwent resection with curative intent for colorectal cancer. These patients were divided into 2 groups based on the occurrence (65 patients, 6%) or absence (1018 patients, 94%) of postoperative complications due to infection. We investigated the demographic and clinicopathological features of each patient with and without postoperative infectious complications, as well as the impact of postoperative infection on long-term survival. Results showed that patients with postoperative infectious complications had diabetes mellitus more frequently and also had urgent surgery compared to those without infectious complications. In addition, patients with postoperative infectious complications had a significantly more unfavorable outcome compared with those without postoperative infection in cancer-specific, but not overall survival. Multivariate analysis demonstrated that age, rectal cancer and tumor stage correlated with overall survival, but not postoperative infectious complications. However, postoperative infections, as well as gender, were associated with the length of time until the patient succumbed from the recurrence of colorectal cancer after resection for curative intent. Thus, postoperative infectious complications are predictors of adverse clinical outcome in patients with colorectal cancer. However, further immunological study is necessary to confirm the biological significance of these findings.

Outcome after emergency surgery in patients with a free perforation caused by gastric cancer.

Perforation of gastric cancer is rare and it accounts for less than 1% of the incidences of an acute abdomen. In this study, we reviewed cases of benign or malignant gastric perforation in terms of the accuracy of diagnosis and investigated the clinical outcome after emergency surgery in patients with a free perforation caused by gastric cancer. On the basis of pathological examination, gastric cancer was diagnosed in 8 patients and benign ulcer perforation in 32 patients. The sensitivity, specificity and accuracy of intraoperative diagnosis by pathological examination were 50, 93.8 and 85%, respectively. Except for age, there were no differences in the other demographic characteristics between patients with gastric cancer and benign ulcer perforation. The median survival time of patients with perforated gastric cancer was 195 days after surgery. Patients with gastric cancer perforation had a poorer overall survival rate than those who had T3 tumors without perforation. In addition, in patients with perforation, recurrence of peritoneum occurred more frequently. In conclusion, to improve the survival rate of patients with perforated gastric cancer and to improve the accuracy of intraoperative diagnosis, endoscopic examination and/or pathological examination of the frozen section should be performed, if possible. A balanced surgical strategy using laparoscopic local repair as the first-step of surgery, followed by radical open gastrectomy with lymphadenectomy may be considered.

Minimally invasive surgery for resection of duodenal carcinoid tumors: endoscopic full-thickness resection under laparoscopic observation.

BACKGROUND: Carcinoid tumors of the duodenum are rare, and the most effective treatment for duodenal carcinoid tumors remains debatable. Because carcinoid tumors of the gastrointestinal tract tend to spread to the submucosal layer even during the early stages of the disease, the possibility of tumor seeding in the vertical margin of the tumor cannot be eliminated by conventional endoscopic mucosal resection (EMR). In addition, because the duodenal wall is thinner than the gastric wall, EMR performed for duodenal lesions may be associated with a high risk of accidental perforation. In this article, we introduce a minimally invasive endoscopic full-thickness resection technique after laparoscopic repair for the local resection of duodenal carcinoid tumors. METHODS: Under general anesthesia, after the duodenum was mobilized laparoscopically, the duodenal serosa at the site of the lesion was suctioned under laparoscopic observation, and full-thickness resection of the duodenum was performed using a cap-fitted endoscope, i.e., EMR-c, without injecting hypertonic saline-epinephrine. The sample was retrieved endoscopically after resection. After confirming that the full-thickness resection of the duodenal wall with enough surgical margins was achieved and that there was no active bleeding, the wound was sutured by the laparoscopic hand-suturing technique. RESULTS: We have performed this surgical procedure in two cases of duodenal carcinoid tumor. The mean operation time was 116 +/- 14 minutes, and the estimated blood loss was 2.5 +/- 0.5 ml. The postoperative courses were uneventful in both cases. CONCLUSIONS: The technique of endoscopic full-thickness resection of gastrointestinal tract under laparoscopic observation is a safe, simple, and can be radical surgical procedure for a small duodenal carcinoid tumor. This surgical procedure may be applicable in the case of other gastrointestinal tumors.

Limited gastrectomy with dissection of sentinel node stations for early gastric cancer with negative sentinel node biopsy.

OBJECTIVE: To evaluate the early results of sentinel node (SN)-navigated limited surgery for early gastric cancer. SUMMARY BACKGROUND DATA: False-negative results of SN biopsy cannot be ignored in gastric cancer surgery. Previous studies suggest that dissection of lymph node stations where SNs belong (SN stations) may minimize the possibility of leaving metastasis behind in SN-navigated surgery. METHODS: Patients with T1N0M0 gastric cancer <4 cm were informed about the SN-navigated limited surgery from 2003 to 2008. SNs were identified using radioisotope and dye methods. When the SN biopsy by frozen section was negative, limited gastrectomy with dissection of SN stations was performed. Patients with SN stations limited to either the lesser or greater curvature underwent a wedge resection unless it would cause a strong deformity of the stomach. A sleeve gastrectomy was performed in other cases. RESULTS: Six of the 60 enrolled patients chose a standard gastrectomy. Sixteen patients were excluded after laparotomy due to a T2-T3 tumor or tumor location. Three patients with positive SN biopsy underwent D2 gastrectomy, and 35 with negative SN biopsy underwent limited gastrectomy with dissection of SN stations; wedge resection in 8 and sleeve gastrectomy in 27. There were no operative mortalities or morbidities. All patients undergoing the limited surgery had no lymph node metastasis by postoperative pathology, and survived without any recurrence. The average area of the resected stomach for limited surgery was significantly smaller than that for standard procedures (92 +/- 50 vs. 189 +/- 64 cm, P < 0.001). CONCLUSIONS: SN-navigated limited gastrectomy with dissection of SN stations for T1N0M0 gastric cancer was considered safe and acceptable although long-term follow-up is mandatory.